Elsevier

The Lancet

Volume 397, Issue 10273, 6–12 February 2021, Pages 543-554
The Lancet

Series
Delivering health and nutrition interventions for women and children in different conflict contexts: a framework for decision making on what, when, and how

https://doi.org/10.1016/S0140-6736(21)00133-1Get rights and content

Summary

Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict.

Introduction

Marking 20 years since its formation as a joint initiative of several agencies aiming to improve humanitarian response, the Sphere Project released the fourth edition of its widely used Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response1 in 2018. That year also saw the launch of the newly revised Inter-Agency Field Manual on Reproductive Health in Humanitarian Crises2 from the Inter-Agency Working Group on reproductive health in crises and the newly developed Newborn Health in Humanitarian Settings: Field Guide3 produced by WHO, UNICEF, and Save the Children. The Infant Feeding in Emergencies (IFE) Core Group introduced an update of the Operational Guidance on Infant and Young Child Feeding in Emergencies4 in 2017, the same year that the Global Nutrition Cluster updated its Moderate Acute Malnutrition: a Decision Tool for Emergencies,5 and the first edition of the Oxford Handbook of Humanitarian Medicine6 was published in 2019. New releases such as these help to address the widely acknowledged need for more technical and operational guidance to inform decision making for humanitarian health and nutrition response,7 and they are proof of sustained commitment to continually improve humanitarian health and nutrition practice.

These new resources complement and expand pre-existing guidance on humanitarian health and nutrition action, including the ten top priorities outlined by Médecins Sans Frontières in its influential 1997 publication Refugee Health: An Approach to Emergency Situations.8 Aimed at preventing and reducing excess mortality among displaced populations, these ten public health priorities (panel) continue to be recognised as essential components of an initial emergency response, along with other emerging priorities in crisis contexts such as non-communicable disease treatment and mental health and psychosocial support, among others. Such guidance is and should be iterative, evolving as evidence and insights mount. For example, lessons learned from the unique challenges of humanitarian response to major infectious disease outbreaks, such as Ebola virus disease in west Africa, have been invaluable for developing operational responses in other settings.9, 10 From the current global response to COVID-19, a plethora of guidance has already emerged, including for maintaining essential health and nutrition services in the midst of the pandemic.11

Most existing resources are generic, intended for use with a range of populations in a range of humanitarian emergencies. Current guidance on addressing the health and nutrition needs of women, newborns, children, and adolescents (hereafter referred to as women and children) specifically in conflict settings is scarce in comparison. A review of existing guidance documents relevant to women and children in conflict settings found that where evidence-based recommendations do exist, they generally do not differentiate between conflict situations and other crises such as natural disasters and epidemics; where they do, the contextualisation of the recommendations and their translation into practical actions is insufficient.7 Given the particular needs of women and children affected by conflict and the particular access and resource constraints that armed conflict can impose on efforts to address those needs, relevant guidance must take context into account, including the various dimensions of conflict that drive morbidity and mortality, and that can drastically affect the feasibility of intervention delivery.

Key messages

  • Guidance and recommendations on promoting women's and children's health and nutrition in humanitarian crises exist, but they are not sufficiently contextualised for optimal use in conflict settings

  • A framework for prioritising interventions that takes account of local burden and risks, the range of potential interventions to address them, and the feasibility of delivering those interventions in different conflict contexts would both empower decision makers and make them more accountable for what ultimately gets delivered

  • Packages of priority interventions derived from an illustrative application of such a framework reflect what might be viable to deliver in different conflict settings characterised by different levels of violence and population mobility and high burden of a range of conditions and needs:

    • In conflict epicentres, where violence is acute and ongoing, the personal safety of both care seekers and care providers outweighs the imperative to provide comprehensive services; still, a small set of medically urgent life-saving interventions should be prioritised in such settings

    • In insecure areas, where the threat of violence might be imminent but the population is not presently exposed to active conflict, a wider range of community, facility, and hospital-based interventions should be prioritised; given insecurity and risks, however, the sequencing of higher and lower priority interventions for immediate and subsequent implementation is recommended

    • Where displaced populations are settled in stable camps or integrated amongst host communities, there are generally fewer constraints on service delivery and a full, comprehensive package of relevant interventions should be prioritised, targeting those in greatest need

  • Further iteration and use of a decision making framework to take account of additional contextual factors could help fill the urgent need for contextually adapted guidance on promoting the health and nutrition of women and children in conflict settings

The shortage of contextualised guidance for delivering health and nutrition interventions to women and children in conflict settings reflects the limited evidence available in the relevant literature. Both the quantity and quality of health and nutrition intervention research in humanitarian contexts is insufficient,12 and recent systematic reviews from the Bridging Research & Action in Conflict Settings for the Health of Women & Children (BRANCH) Consortium13 have highlighted important gaps in the literature on the delivery and effects of health and nutrition interventions for women and children affected by conflict.14, 15, 16, 17, 18, 19, 20 Gaps exist in terms of the subpopulations and morbidities or conditions targeted by the interventions reported in the literature, and in the amount of information on how interventions are delivered and what coverage and effectiveness is achieved.

Most of the relevant literature reports on intervention delivery to refugee women and children living in camps rather than to those integrated among host communities or to internally displaced or entrapped women and children. Even within the larger literature on camp-based refugee populations, there is limited reporting of interventions targeting newborns or adolescents, of interventions targeting some major infectious causes of morbidity and mortality such as pneumonia, and of interventions targeting non-communicable disease. Most of the literature reports on interventions delivered at facilities by skilled health personnel rather than through community-based platforms. Very little of the literature captures coverage of reported interventions, and even less information is available about the extent to which such interventions improve outcomes among women and children affected by conflict.

Some of the gaps in the literature indeed reflect actual intervention gaps in the field. In the third paper of this Series, Neha Singh and colleagues21 synthesise a set of recent case studies by the BRANCH Consortium on the provision of women's and children's health and nutrition services in ten conflict-affected countries, which underscore the relative neglect of reproductive health interventions, for example, as well as newborn and adolescent health services.21 But some of the literature gaps surely also reflect the challenges of collecting data and information in conflict settings and the many constraints on humanitarian health responders' capacities and time that hinder the rigorous evaluation of intervention and implementation effectiveness. Such constraints also discourage the systematic documentation of programmatic parameters (eg, delivery personnel and platforms) and lessons learned; information that can be captured relatively easily and, when publicly archived, could constructively inform future programming.

With such a sparse evidence base from which to derive conflict-specific guidance on health and nutrition interventions for women and children, we propose a conflict-specific decision making framework as a preliminary step toward filling that guidance gap.

The proposed framework is based on a conceptual model developed by the BRANCH Consortium to guide its thinking about intervention delivery in different conflict contexts (figure 1), and is also informed by the existing framework for decision making on vaccination in humanitarian emergencies22 first developed nearly a decade ago by WHO's Strategic Advisory Group of Experts on Immunization (SAGE), including some founding members of the BRANCH Consortium (ZAB and RJW). The proposed framework complements the existing body of guidance on addressing the health and nutrition of women and children in humanitarian settings more broadly, and is intended to help decision makers in conflict settings better navigate and adapt that broader guidance in specific contexts. The framework outlines a process by which decision makers in a given conflict setting can systematically select the most appropriate subset of recommended interventions for women and children that can be feasibly delivered in that setting.

In this Series paper, we describe the development and components of the proposed framework and then apply the framework to a set of hypothetical conflict contexts to illustrate the framework-guided selection of interventions for women and children in those contexts. We outline some additional considerations that real-world applications of this framework might also include, and we call for local and international colleagues to help improve this framework further.

Section snippets

Developing a decision making framework for prioritising health and nutrition interventions for women and children in different conflict contexts

Not all required interventions are made available to communities in humanitarian crises, including communities affected by conflict.12, 21, 23, 24, 25 Different humanitarian contexts pose different challenges, and those organisations and agencies delivering health, nutrition, and other interventions in each context must make crucial decisions about what they can and cannot provide under prevailing conditions and to whom, essentially practicing public health triage.26

Given this need to triage in

Illustrative application of the decision making framework in different conflict contexts

To illustrate what the framework-guided selection of interventions for women and children might look like in different conflict contexts, we apply the decision making framework to the three hypothetical contexts derived from our conceptual model: conflict epicentres, insecure areas, and secure areas.

Conflict epicentres or hotspots

The intervention priorities identified by applying the proposed decision making framework to each conflict context are shown in the table. Given the extreme insecurity in conflict epicentres and the potential risks of death, injury, abduction, or other hazards for both care seekers and care providers, only a small proportion of the 77 candidate interventions are prioritised for delivery in this context. Often in conflict epicentres, the personal safety of care seekers and care providers will

Adaptation and real-world application of the framework

We emphasise that these three packages of prioritised interventions are illustrative rather than prescriptive, derived by applying a systematic decision making approach to hypothetical conflict contexts. The same approach taken by a different set of participants with different experiences and viewpoints could yield different priorities, given the contextual realities of specific conflict scenarios. Nonetheless, the illustrative packages presented in this Series paper offer a view of what might

References (43)

  • Newborn health in humanitarian settings: field guide

  • Operational guidance on infant feeding in emergencies (OG-IFE) version 3.0

  • Moderate acute malnutrition: a decision tool for emergencies

  • S Aboubaker et al.

    The availability of global guidance for the promotion of women's, newborns', children's and adolescents' health and nutrition in conflicts

    BMJ Glob Health

    (2020)
  • Refugee health: an approach to emergency situations

    (1997)
  • P Piot et al.

    Emergent threats: lessons learnt from Ebola

    Int Health

    (2019)
  • ZF Dembek et al.

    Operational perspective of lessons learned from the ebola crisis

    Mil Med

    (2017)
  • Maintaining essential health services: operational guidance for the COVID-19 context

  • ZA Bhutta et al.

    Protecting women and children in conflict settings

    BMJ

    (2019)
  • RP Jain et al.

    Delivering trauma and rehabilitation interventions to women and children in conflict settings: a systematic review

    BMJ Glob Health

    (2020)
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